August 8–9, 2017—Summary Report Page | 1 

CDC/ATSDR TRIBAL ADVISORY 

COMMITTEE MEETING

The Centers for Disease Control and Prevention (CDC) and the Agency for Toxic Substances and 

Disease Registry (ATSDR) hosted the Tribal Advisory Committee (TAC) Meeting and 17th 

Biannual Tribal Consultation Session on August 8–9, 2017, at the Artesian Hotel, in Sulphur, 

Oklahoma. During the two-day meeting, TAC members held discussions with CDC and ATSDR 

representatives. 

Topics included CDC’s budget, tribal strategies for connecting cultural practices in competitive 

funding opportunities, Zika virus response, and tribal public health priorities. 

Tuesday, August 8, 2017 

Tribal Advisory Committee Business

The session highlighted strategies to improve the structure of biannual TAC meetings. The Tribal Support 

Unit (TSU) shared ideas about identifying opportunities, enhancing engagement, and seeking other

approaches and methods to disseminate information. TSU spoke about its new internal mechanism for 

tracking tribal inquiries and TAC meeting evaluations. The system will be piloted after the Summer 2017 

TAC meeting has been completed. 

CDC Office of the Director Updates 

Dr. José Montero, director, Office for State, Tribal, Local and Territorial Support (OSTLTS), deputy 

director, CDC, announced the appointment of Dr. Brenda Fitzgerald as the 17thCDC director and ATSDR 

administrator. 

Dr. Montero discussed CDC’s opioid overdose prevention work in American Indian/Alaska Native (AI/AN) 

communities and addressed the Department of Health and Human Services’ (HHSs’) five-part strategy to 

combat the opioid epidemic. He highlighted that AI/AN populations continue to be affected 

disproportionately by various types of intentional and unintentional injuries, including opioid overdose. 

Dr. Montero also addressed how social determinants of health have created an environment in which 

injury prevention efforts have not been as successful as they have been in non-Native communities of 

similar socio-economic status. He shared that the strategic collaboration between tribal public health 

experts, tribal leaders, and the National Center for Injury Prevention and Control (NCIPC) to increase the 

cultural relevance of intervention strategies has been successful in lowering death rates attributed to 

motor vehicle injuries in the past decade. 

Dr. Montero provided updates from CDC’s centers, institutes, and offices— 

• NCIPC released the “Guideline for Prescribing Opioids for Chronic Pain” in March 2016 to help 

primary care doctors provide safer, more effective care for patients with chronic pain. 

• The National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention is working with Indian 

Health Service (IHS) to analyze existing data sources that could inform IHS about regions and 

counties at potential risk for spread of HIV and hepatitis C virus.
August 8–9, 2017—Summary Report Page | 2 

• The National Center on Birth Defects and Developmental Disabilities (NCBDDD) is working to 

improve the availability and quality of data to help inform clinical management decisions for 

healthcare providers of women of all races/ethnicities who are pregnant or could become 

pregnant. 

• The Division of Reproductive Health, in CDC’s National Center for Chronic Disease Prevention 

and Health Promotion (NCCDPHP) has provided epidemiologic assistance—providing claims data 

and documenting substance use during pregnancy—related to the prevalence of maternal 

substance use (including opioids and neonatal abstinence syndrome) in the Sisseton Wahpeton 

Oyate and the Cheyenne River Sioux tribes.

Dr. Montero described tribal activities in the CDC Emergency Operations Center. The CDC Incident 

Management System’s State Coordination Task Force (SCTF) includes a new tribal liaison officer position

to facilitate working with tribes during emergency preparedness events. TAC members had the 

opportunity to ask questions about the opioid epidemic, public health infrastructure, and funding issues. 

Zika Virus Update 

Ms. Stephanie Dulin, deputy director, NCBDDD, spoke about health consequences associated with Zika 

and the US Zika Pregnancy and Infant Registry. She described tribal engagement efforts by CDC’s

Emergency Response Team and collaborative activities with the National Indian Health Board (NIHB) and 

the American Mosquito Control Association. 

Lt. Governor Jefferson Keel, Oklahoma Area delegate, participated in the session and asked about the 

reporting of AI/AN children infected with the Zika virus. Ms. Dulin stated there are no AI/AN data about

the percentage of children with congenital Zika syndrome. He inquired about the tribal health systems’ 

access to vaccines and availability in tribal formularies. Ms. Dulin replied that private companies are 

developing vaccines with public funds, and that implementation and dissemination plans are being 

discussed. 

Chairwoman Cheryl Andrews-Maltais, Nashville Area delegate, asked about the tribal outreach efforts, 

vaccine effectiveness for AI/AN women, and best practices for prevention of Zika virus. Ms. Dulin stated 

the Biomedical Advanced Research and Development Authority is leading the vaccine development. She 

will make an inquiry with the Biomedical Advanced Research and Development Authority regarding the 

AI/AN inclusion in testing. She stated most cases in US states have been in US territories or travelassociated cases that did not originate in the states. 

CDC Budget Overview 

Ms. Jenny Sewell, public health analyst, Office of Financial Resources, CDC, and Ms. Georgia Moore, 

associate director for policy, OSTLTS, CDC, provided an FY2017 budget summary. Dr. Ursula Bauer, 

director, NCCDPHP, CDC, provided an update about funding from that center. Ms. Sewell compared the 

FY2017 to the FY2016 distribution of funding. In 2016, CDC funding was decreased for immunization, 

sexually transmitted infections, tobacco, heart disease and diabetes, environment, workforce, and 

occupational safety. Funding was increased for the National Diabetes Prevention Program, birth defects, 

opioid prevention programs, and global health programs. Ms. Sewell addressed the president’s budget 

request for FY2018, a decrease in CDC’s budget from $7.2 billion in FY2017 to $5.976 billion in FY2018. 

She reported FY2018 House Appropriations Committee budget estimates for CDC program funding is 

$7,001.5 million, a decrease of $198.4 million compared to FY2017. 

Ms. Moore presented updates about CDC/ATSDR funding to tribes and tribal organizations. Ms. Moore 

discussed analysis of funding streams and the difficulties with tracking funding. She stated that her team 
August 8–9, 2017—Summary Report Page | 3

commits to having an analysis that shows FY 2017 funding that supports tribes by the winter 2018 TAC 

meeting. 

Dr. Bauer provided an update from NCCDPHP—

• NCCDPHP received $34 million for the Racial and Ethnic Approaches to Community Health 

Program in the FY17 budget, a decrease of $16 million from the continuing resolution.

• NCCDPHP received $16 million for the Good Health and Wellness in Indian Country – a new 

budget line to support activities described in the FY17 President’s Budget Proposal. 

• To cover the deficit between the $50 million and the $34 million, NCCDPHP reduced 

investments internally and to REACH grantees. 

Dr. Bauer described NCCDPHP’s support for tribal epidemiology centers (TECs)—

• NCCDPHP deployed about $8.5 million of the new FY17 funds to TECs to follow through with the 

program description contained in the Budget Initiative. 

• In the fall, NCCDPHP will use $5 million to support a notice of funding opportunity (NOFO) for 

tribes and urban Indian health centers. 

Dr. Bauer stated that NCCDPHP will make progress to support cultural practices and learn what connects 

people to culture. She explained that the NOFO has been designed based on several years of input from 

tribal convenings, NIHB listening sessions, and meetings with Indian health boards and tribes. Dr. Bauer 

requested the TAC’s input on funding amounts so NCCDPHP can fund as many tribes as possible and 

support effective programs. 

Melanie Fourkiller, policy analyst, Choctaw Nation Health Services, addressed the need for consistent 

and reliable funding (funding that does not have to be negotiated every year) for tribal public health 

infrastructure. She suggested an approach where tribes could compete among themselves for a 

percentage of CDC’s budget designated for Indian Country. Ms. Fourkiller addressed the NCCDPHP 

NOFO that was released on August 7 and asked if there was a directive to restrict that to TECs, or if CDC 

was required to restrict it in some way. Dr. Bauer responded that the $42 million would fund activities 

over five years, which is equivalent to about $8.5 million each year. She described the new funding 

opportunities as bringing to fruition the plans previously discussed at TAC meetings and through 

listening sessions and described in the President’s FY17 Budget Proposal. 

Mr. Larson, Tribes At-Large Delegate, commented on the need for clarification of tribal needs so tribes

have a basis for TAC members to work on crafting a budget initiative to fund tribal public health.

Ms. Moore announced an innovative emergency response NOFO that will identify tribal response 

opportunities and capacities so that when a tribe is in need of a response, CDC can identify needs and 

match funding to reach tribes. 

In an effort to address the issue of tribes competing with states for funding, TSU is creating a tip sheet 

for project officers who write NOFOs. CDC will continue to rank the proposal separately for states, 

tribes, and large cities and fund each group accordingly. This focus will provide another opportunity to 

reach tribes. Dr. Bauer commented that NCCDPHP does fund tribes directly and meets the 2% threshold 

that the tribes are requesting. She asked for ideas about specific funding arrangements that will provide 

adequate, consistent, and reliable funding.
August 8–9, 2017—Summary Report Page | 4 

Lt. Governor Keel commented on the tribal-state relationship, saying that many states have good 

relationships with tribes, but there is no legislation that requires states to work with them. He addressed 

the need for tribal advocacy to Congress to use legislative language that directs funding to tribes. He 

commented on how he believes agencies use legislative language as a crutch to avoid or justify not 

funding tribes. 

Tribal Councilor Bryan Warner, Cherokee Nation, inquired about congressional direction to CDC to make 

the new NOFO available only to TECs. Dr. Bauer explained that CDC followed the plan described in the 

FY17 President’s Budget Proposal. The language in that Budget Initiative was crafted over the past two 

years with input from the TAC and others, and build on the Indian Health Care Improvement Act of 2010 

and language directing CDC to provide support for the TECs. Dr. Montero added that TSU has a 

cooperative agreement with NIHB to conduct a scan of public health capacity in Indian Country. 

TAC Chairman, Councilman Chester Antone concluded the session. 

Overview of Public Health Programs 

Mr. Bobby Saunkeah, manager, Research and Population Health Division, Chickasaw Nation Department 

of Health (CNDH), started the panel discussion by explaining the background and diversity of Native 

presence in Oklahoma. He concluded by stating that Oklahoma’s diversity presents unique challenges 

when tribes apply for grants because the community is often pre-defined for them. Panel members 

suggested that the definition of “community” be less restrictive in NOFOs. In addition, Mr. Saunkeah 

mentioned that the lack of quality public health data (in terms of demographics) creates a challenge 

with tribal data. The panel members explained that tribes are using clinical data because tribal public 

health data is difficult to collect. This issue emphasizes the need for direct funding for tribes to build the 

public health workforce and infrastructure at CNDH. 

Panel members provided a brief overview of project implementations in the Chickasaw Nation— 

• Dr. Valarie Jernigan, associate professor, College of Public Health, University of Oklahoma Health 

Sciences Center described “A Mobile Food Basket Study and Initiatives on Farmers Markets” 

• Miranda Willis, strategic prevention data analyst, Chickasaw Nation explained “Define Your 

Direction,” a social media campaign that reaches more than 3,000 people per message; social 

media staff promote services and tools in Chickasaw Nation 

Next, the award-winning “Define Your Direction” video was played and received a positive response 

from audience members. 

Cultural Practices and Mental Health Prevention Programs 

Panelists presented about Chickasaw Nation’s clinical research and the impact of cultural connectedness 

on health outcomes. Presenters shared the Chickasaw Nation’s work to integrate behavioral health 

services to create a system-wide approach to domestic violence programs, opioid abuse, and their Zero 

Suicide Initiative. 

Panel participants were— 

• Shannon Dial, PhD, LMFT, executive officer, Integrated Services Division, Department of Family 

Services, CNDH

• Kelly M Roberts, PhD, LMFT, family initiatives advisor, Department of Family Services, CNDH
August 8–9, 2017—Summary Report Page | 5

Dr. Dial provided a brief history of how Chickasaw Nation implemented strategies in its emergency 

rooms, such as standardizing their depression screening process. She emphasized that other tribal 

health systems can easily replicate their screening system for depression and opioid abuse. She 

described the model and the impact of embedding behavioral health providers into general clinics and 

emergency rooms. Chickasaw Nation was able to increase the reach and impact of behavioral health 

services. The approach resulted in a 152% increase in access to behavioral health care in three years. 

Before integration, the system had about 400 behavioral health patient encounters per month; now it 

averages closer to 1,100. 

Dr. Roberts shared that the extent of integration is so successful that it is difficult to distinguish the silos 

that existed previously. Now, all partners are engaged and share the responsibility. Dr. Roberts provided

details of their violence prevention activities and shared the following notes from Chickasaw Nation 

leaders:

• Chickasaw Nation has a 24-hour on-call service and is ready to respond.

• Chickasaw Nation collaborates closely with its medical team; coordination is strong and solid.

• A new facility that will quadruple the space for shelter services is under construction.

• Regarding violence prevention, domestic violence nurse examiner and sexual assault examiner 

are distinct roles; the certification and the follow-up process with patients are different. 

Chickasaw Nation is also exploring the distinction from an elder abuse role.

• In all Chickasaw Nation clinics, domestic violence nurse examiners address all intimate partner 

assaults, including strangulation, which has increased. Examiners encourage patients to have a 

medical screening and hospital monitoring after such an event.

• Chickasaw Nation reviews each case to identify possible improvements to the process to

comprehensively address and implement trauma-informed care.

Dr. Roberts shared that the interdisciplinary group working on violence includes police, chaplains, 

nurses, and social services. All of these professionals train continuously to increase their knowledge and 

skills around trauma-informed care.

Dr. Roberts expressed the critical importance of reflecting the Chickasaw Nation culture in the care 

environment. She described a process they began two years ago to explore how culture can be

incorporated in therapy protocols throughout the system of care. She first defined “historical trauma” as 

trauma passed on through generations. Chickasaw Nation considered how to include elements of 

culture in treatment plans to enhance identity, cohesiveness, and awareness. They explored an 

American Indian Enculturation Scale.

Dr. Roberts explained that “enculturation” is reintroducing people to their first culture. After a pilot 

study, Chickasaw Nation determined that the AI Enculturation Scale was too pan-Indian and generic to 

resonate with Chickasaw people. Chickasaw Nation elders met with the Chickasaw Nation cultural 

department and identified 38 items that should appear in a Chickasaw Nation Enculturation Scale. The 

Chickasaw Nation Internal Review Board (IRB) Office further refined and strengthened the tool. 

Eventually the Chickasaw Nation health clinics tested it and determined that it is valid and reliable. The 

tool includes three primary measures: Satisfied Subscale, Identity Subscale, and Enculturation Subscale. 

In the pilot test, all subscales were above 0.8 with a variance of 0.61. Two-hundred-and-fifty Chickasaw 

participated in the preliminary test phase. Chickasaw Nation will now use the instrument to measure the 

impact of its efforts to incorporate a sense of identity and cohesion into wellness plans. 
August 8–9, 2017—Summary Report Page | 6 

At the conclusion of Dr. Roberts’s statements, Councilman Antone opened the floor to the TAC 

delegates, invited CDC senior leaders, and other Tribal Nation leaders to sit at the table for questions 

and answers.

Chairwoman Cheryl Andrews-Maltais commented on the “extraordinary achievement” of this effort. She 

was excited to see the pilot outcomes and recounted that she often sees that the lack of a “cultural 

rudder” limits the recovery of AI/ANs from incarceration and drug addiction. 

Dr. Montero congratulated the doctors on their “amazing work.” He stated that before working at CDC, 

he was not able to get his organization to a 100% depression screening at all points of entry. He asked 

the panelists about the organizational capacity to manage demand generated from the screenings.

Dr. Dial confirmed that their success always drives a demand for more behavioral health workers to 

meet the identified need. The integrated visits reflect a low effort, touch base-style interaction. All of 

the behavioral health providers now see 10–16 patients a day, as opposed to seeing only 6 previously. 

Chickasaw Nation has great communication between providers and patients. 

Dr. Roberts stated that learning clinical patterns has been key to maximizing their capacity. Learning the 

best communication channels is crucial to make the team more efficient. Dr. Dial also asserted that 

integrated care depends on the quality of staff hired. Certain personality traits and high confidence in 

the behavioral health clinician are critical. 

Councilman Antone thanked all panel members and noted that culture is a protective component of 

mental health and wellbeing. He stated that cultural practice is not pan-Indian and that the strength of 

Native people is in their unique historical and cultural identities. He applauded Chickasaw Nation for 

presenting a model and for finding the power to make their people stronger and more resilient. 

Health Policy and Law 

This session explored the legal framework of tribal sovereignty and tribal engagement with other health 

law partners while maintaining tribal sovereignty. 

Debra Gee, general counsel, Chickasaw Nation Legal Division, introduced the session by defining 

“sovereignty” as the inherent right to govern. She spoke about how the organizational structure of 

tribes in Oklahoma makes jurisdictional determinations challenging. 

Kim Cravatt, assistant general counsel, Chickasaw Nation, presented examples of tribal health law and 

policy interventions that have affected tribes, including Chickasaw Nation. These included tribal food 

safety interventions; 53 tribes have adopted food safety codes. The use of policy and law to address the 

opioid epidemic is of special interest in the current state of health. Ms. Cravatt reported that Oklahoma 

ranks nationally in the top five states for opioid prescribing rates and the top ten for high-dose opioid 

prescriptions. 

Carolyn Romberg, director, Chickasaw Nation Legal Division, presented about mental health and law. 

She stated that recognizing the close connection between illicit drug use and mental health issues, the 

Oklahoma court system created a unique set of specialty courts termed “drug courts.” The model, 

developed by the State Department of Justice, allows local jurisdictions, like Chickasaw Nation and other 

community partners, to collaborate with the court to provide services to Chickasaw people who face 
August 8–9, 2017—Summary Report Page | 7 

drug charges. The Chickasaw Nation’s ultimate goal is to have its own mental health court. Securing 

hospital admissions for Chickasaw people caught in the court system has been far easier to accomplish

with the integration of Chickasaw Nation health services. This work is carried out under executive 

directives from Chickasaw Nation’s governor. Ms. Romberg concluded by stating that the policies and 

procedures have been adopted to support this direction because legal codes can be far more difficult 

and time consuming to change. 

The panelists shared that the Cherokee Nation Legal Division reviews grant opportunities and has seen 

that it is a challenge for tribes be successful applicants when they have to compete with states. The 

nation advises that this be kept in mind as CDC develops future NOFOs. 

Councilwoman Delia Carlyle, TAC delegate, Phoenix Area, stated that the severity of the opioid abuse 

continues to grow due to lack of professional care and expertise for patients who are prescribed 

narcotic medications for pain management. 

Ms. Romberg responded that Oklahoma does have a prescription drug monitoring system and that both 

providers and pharmacists can review prescribing records in this system. In addition, Chickasaw Nation 

employs a pain management contract within its clinics to support the pain management policy. This 

allows doctors who prescribe narcotics to hold patients accountable for compliance. If a patient violates 

the policy, then the physician will no longer prescribe narcotics to that patient. 

Councilwoman Carlyle described that other factors contributing to the increase in opioid abuse include 

the lack of continuity of care in the Ak-Chin Indian community, few pain management doctors, and the 

lack of shared access to health record information for prescribing providers. Councilwoman Carlyle 

asked the panel if they had any experience with “medical marijuana cards.” Panelists responded that 

they have a zero tolerance policy regarding marijuana. Ms. Romberg shared that Oklahoma has not 

adopted a medical marijuana or recreational use statute.

TAC Chairman, Councilman Antone concluded the session. 

Wednesday, August 9, 2017 

Tribal Public Health Accreditation Panel 

Ms. Lisa Pivec, senior director of public health, Cherokee Nation, presented a brief overview of the 

Cherokee Nation accreditation process. She reviewed the standards, extrapolated what was important, 

and explained how Cherokee Nation compared to other types of public health departments, such as 

large municipalities and states, going through the accreditation process. 

Ms. Pivec then presented a brief overview of Cherokee Nation— 

• Multi-jurisdictional, with 14 counties and a tribal jurisdictional service area spanning 9200 

square miles

• Home to more than 315,000 citizens 

• 210,000 members live in Oklahoma 

• 140,000 reside in a tribal jurisdictional service area 

• Has a great relationship with the Tribal Public Health Advisory Committee to the State 

Department of Health 
August 8–9, 2017—Summary Report Page | 8 

Ms. Pivec commented that tribes will never have enough direct care dollars, and the focus should be on 

healthier communities. Ms. Pivec presented the following timeline describing their accreditation 

process: 

• 2007—Began exploring accreditation

• 2009 to 2010—Participated in a Public Health Accreditation Board (PHAB) beta test, which 

helped them to be successful in the application process

• 2011—Received National Public Health Improvement Initiative (NPHII) funding of $800,000 for 

four years; it didn’t completely fund their work but did help

• 2012—Completed the National Public Health Performance Standards Program

• 2013—Applied for accreditation; NPHII funding covered the $25,000 cost to apply for 

accreditation 

• 2014—Uploaded all documents to the e-PHAB system 

• 2015—Hosted a site visit with the PHAB team

• 2017—Received accreditation; Cherokee Nation is the first tribe to receive accreditation 

For next steps, Ms. Pivec and her staff are developing a conceptual map for organizational design and 

are still struggling to implement what they have documented. They will put the conceptual map into an 

organizational design they can implement practically into their health system. Ms. Pivec concluded that 

tribal public health infrastructure needs to be a priority. Tribes need people to do the work, through 

both workforce capacity and technical assistance. Tribes also need to have consistent funding 

mechanisms and to be eligible for NOFOs, as well as have access to successful state models. 

Councilman Antone asked Ms. Pivec to elaborate on the complexities of public health accreditation 

process across multiple counties in Cherokee Nation. Ms. Pivec said that fewer counties means fewer 

cross-jurisdictional issues. She suggested looking at the conceptual map to identify what his tribe 

already does, which partnerships could create access to public health programs and services, and then 

what public health infrastructure they need to build. She emphasized that passing a public health code 

would be the best place to start. Ms. Pivec stated that PHAB can help with guiding the process and 

establishing performance measures. Dr. Montero and Lt. Governor Keel thanked Ms. Pivec and

congratulated Cherokee Nation on its accreditation. 

Lt. Governor Keel discussed the need for creative financing to go through the accreditation process. 

There are tribes that are interested; some are already doing many of the accreditation activities

mentioned, but without sufficient funding, some do not see why they should pursue it. He encouraged 

her to reach out to other tribes. 

TAC Chairman, Councilman Antone concluded the session. 

Chickasaw Nation Youth Wellness Clinic Panel 

This session described how Chickasaw Nation addresses pediatric obesity treatment through its multidisciplinary behavioral modification clinic. It highlighted the collaboration with Chickasaw Nation’s 

public health teams, including a research component and an external collaboration with Oklahoma 

University Children’s Hospital. 

Mr. Saunkeah provided the background for the presentation, explaining that the clinic concept formed 

out of the relationship between clinical and public health work addressing obesity. The clinic focuses on 
August 8–9, 2017—Summary Report Page | 9

wellness behaviors, including behavioral modification with goal setting, rather than just weight control 

and monitoring. All factors that contribute to obesity in children, such as sleep patterns, physical 

activity, and relationship building, are considered. 

Dr. Neilsson Rais, pediatric medicine specialist and general practitioner, Chickasaw Nation Medical 

Center, stated that he was seeing a vast array of comorbidities in children directly linked to their weight, 

so knew there was a need for intervention that adequately addressed pediatric obesity. Dr. Rais said 

that to achieve the greatest success in addressing pediatric obesity, it is incumbent on healthcare 

providers to engage the parents. He concluded by stating that at the Empowered Living Clinic, the goal is 

to show families how small changes can make a big difference in these complicated diagnostic measures 

that they might not understand. 

Next, Jeff Wells, physical therapist, Empowered Living Clinic, emphasized that this approach is unique. 

The clinic has collaborated with Healthy Futures, a non-profit organization dedicated to supporting 

positive youth development. Mr. Wells stated that a physical therapist’s role is to rule out 

musculoskeletal issues and identify any limitations that might keep a patient from obtaining physical 

activity goals. 

Dr. Ashley Weedn, assistant professor, General and Community Pediatrics, University of Oklahoma 

Health Sciences Center and medical director, Healthy Futures, University of Oklahoma, stated that the 

model for the program came from the expert pediatric committee on obesity; the committee includes 

members from CDC, the Health Resources and Services Administration, and the American Medical 

Association. In 2012, Oklahoma University Health Science Center developed and implemented the 

model in Oklahoma and began to study its impacts. In 2014, the Empowered Living Registry was created

for every academic center or community team to report data. 

Dr. Weedn stated that, from a research perspective, the next steps are to begin evaluating the registry. 

Since the Empowered Living Clinic is a closed system, it is possible to explore the family impacts of the 

clinic rather than only effects on the pediatric patient. Chickasaw Nation has the only community-based 

multidisciplinary team—all other teams are academic institutions—making Chickasaw Nation’s clinic 

design a unique evaluation opportunity. Dr. Weedn concluded by stating that when a child sets a goal, 

each family member supporting that child commits to that change as well (e.g., removal of sugary drinks 

from the home). 

Mr. Saunkeah shared that Chickasaw Nation is developing a biorepository as part of the Empowered 

Living Clinic, with infrastructure currently in the planning phase. Lt. Governor Keel thanked the group for 

the presentation and shared his thoughts about how inclusion of the registered dietician in the team is 

valuable because there are native communities across the country who depend on the commodity 

distribution. 

Dr. Montero asked the panel that when it comes to prevention, how they maintain consistency in 

messaging while also addressing cultural needs when health behaviors might be culturally specific.

Dr. Weedn responded that development of cultural messaging is tribe-specific and should occur at the 

tribal level rather than the state level. Mr. Saunkeah responded that the program just received IRB 

approval last month to begin the research piece within the program. Every component has the 

Chickasaw culture embedded in it. Consent forms for participants are being finalized and an application 

for an Empowered Communities grant is with the HHS Office on Minority Health. It is anticipated that 

next year Chickasaw Nation will have data to share.

With this final response, Councilman Antone concluded the session.
August 8–9, 2017—Summary Report Page | 10 

Tribal Data Panel 

This session highlighted issues such as disease surveillance, data protection, and research partnerships.

Mr. Michael Peercy, Epidemiologist/Biostatistician, IRB Administrator, Division of Research and 

Population Health, Chickasaw Nation Department of Health, shared that his staff members focus on the 

surveillance of chronic disease, infectious disease, emerging pathogens, community health assessments, 

outbreaks, and more for the Chickasaw Nation. The division uses many tools to explore community 

health, including geographic information system mapping. In an outbreak response, the division 

frequently encounters complex jurisdictional issues and must work to ensure that all appropriate 

response actions. Mr. Peercy stated that cancer (lack of screening contributes to high rates), motor 

vehicle accidents, and accidental opioid poisonings are leading causes of death. Mr. Saunkeah described 

the Chickasaw Nation IRB and explained the difference between academic IRBs and tribal IRBs. Tribal 

IRBs are charged not only with protecting the individual, but also the tribe as a whole. 

Mr. Peercy then discussed “data sovereignty,” (i.e., data ownership), stating that data sovereignty, as it 

applies to tribes, is the right to govern the collection, use, and storage of its own data. As with most 

tribes, the Chickasaw Nation does not allow for research data transfer or secondary analysis without 

tribal approval. The state health department employs epidemiologists across all of their sections; 

however, tribes might not have an epidemiologist at all, or at best might have one who must take their 

skills and evolve into a “jack of all ‘epi’ trades.” 

Councilman Antone asked about the essential compositions of an IRB. 

Mr. Peercy replied that for federal recognition, an IRB must have community involvement, directorship, 

and a mix of scientists and nonscientific members. A tribe can form a research review board without a 

federally recognized IRB. This would route all research decisions to the council or other designated tribal 

group. Chickasaw Nation chose to have the federal registration, which gives tribes more influence when 

engaged with academic institutions should a difference of opinion occur.

President George Edwardson, Tribes At-Large delegate, shared his personal history regarding research 

abuses within his tribe. 

Mr. Saunkeah responded that this example provides shows why tribes are forming IRBs and exerting 

their sovereign authority to review all potential research. The tribal IRBs can then prevent these abuses.

Representative Robert TwoBears, Billings Area delegate, asked the panel if Chickasaw Nation provides 

insurance coverage for tribal members, and if so, if it shares information with the insurer.

Mr. Peercy replied that there is no close partnership with the insurance company, although there has 

been an effort to break down the barriers in the separate caches of tribally owned data. That would 

help to identify a greater economic impact of prevention activities through sharing.

Mr. Saunkeah shared that the division strives to improve its external communication through its 

newspaper and website and is exploring additional communication strategies, such as community focus 

groups and leadership presentations. Mr. Peercy stated that they share some of the more clinical 

projects within the Chickasaw Nation’s Grand Rounds so that providers have this as quickly as possible.

With no further questions, Councilman Antone concluded the session. 

FITWELSM Built Environment Panel 

Dr. Kimmons, health scientist, Division of Nutrition, Physical Activity and Obesity, NCCDPHP, CDC,

described the connection between the built environment and health behaviors. He explained that a built 

environment can make a healthy lifestyle more accessible, affordable, and sustainable. The built 

environment encompasses social structures, cultural norms, and personal values to change behavior. To 
August 8–9, 2017—Summary Report Page | 11 

improve health outcomes, it is necessary to consider how to better design communities’ built 

environments to support for healthy behaviors. He explained that behavioral choices are reactive and 

driven by sensory exposure, availability, cultural norms, and mindset. Analyzing how design affects 

behavior will allows one to affect individual behavior. 

Next, Ms. Giselle Sebag, Fitwel Ambassador, presented about FitwelSM, a certification system that 

optimizes building design to promote healthy behavior. Ms. Sebag explained how atmosphere can affect 

the brain, using the example that subluminal triggers can affect the vagus nerve and make someone 

irritable. She stated that Fitwel is a high-impact building certification that supports healthier workplace 

environments and improves occupant health and productivity. Fitwel is an independent non-profit 

organization in New York and is currently in its beta phase of product development. CDC and the 

General Services Administration lead the Fitwel effort. 

Next, Dr. Kimmons explained that CDC scientists have researched the link between built environments, 

physical activity, and building structures. Dr. Kimmons and his CDC colleagues spoke about health issues 

that are becoming an increasing priority for Fitwel. These priorities include chronic disease risk factors, 

mental health, social equality for vulnerable populations, occupational safety, and improvements in 

community health. Fitwel’s unique value lies in the fact that all strategies suggested by the certification 

program are voluntary and require no prerequisite strategies that could be cost-prohibitive. 

Dr. Kimmons explained the steps in the certification process. 

Councilman Antone thanked the panel members for their time and concluded the session. 

Association of American Indian Physicians Panel 

Mr. Gary Lankford, program director, Advances in Indian Health Care Students Programs, Association of 

American Indian Physicians (AAIP), shared details about the Data Into Action Project. He stated that the 

evaluation ratings for the Data Into Action Workshop and Grant Writing Workshop have been positive. 

In 2018, AAIP will offer three more workshops in the eastern United States, possibly focusing on tribes in 

North Carolina, New England, or the Great Lakes region.

Ms. Jamie McDaniel, program manager, Million Hearts: Hypertension Control Improvement in Indian 

Country, AAIP, presented more details about AAIP’s Grant Writing Workshop. AAIP worked with June 

Strickland, University of Washington, to develop the Grant Writing Workshop curriculum and to 

implement the workshop in tribal communities. Dr. Strickland implemented in-person workshops in 

Oklahoma City, Oklahoma, and at the University of Washington. Post-workshop evaluations revealed 

that although people gained knowledge, the workshop was not long enough for the attendees to get an 

in-depth understanding that they could use to develop effective proposals. 

Eight AI/AN communities have been funded to incorporate 10 strategies to increase fruit and vegetable 

consumption and 10 strategies to increase physical activity. For example, the Absentee Shawnee Tribe 

used AAIP funding to incorporate two 5- to 10-minute during the workday and add a social support 

component. The tribe had an existing physical activity policy that allowed tribal employees to use three 

hours of paid leave to use either the tribe’s fitness facilities or a preapproved offsite facility, but interest 

eventually dwindled over time. As indicated in CDC’s Winnable Battles initiative, programs with a 

participant support component are more effective. At Absentee Shawnee, the employees turn in 

walking logs and have monthly incentives and awards ceremonies. The tribe also modified the policy 

language from “exercising for fitness” to “exercising for health,” which survey responses indicate is 

more favorable.
August 8–9, 2017—Summary Report Page | 12 

The presenters described a few more Urban Indian programs focused on policy systems and 

environmental changes— 

• The Indian Child and Family Preservation Program’s work centers on the Indian Child Welfare 

Act compliance and supervised visits. The program is based in California. 

• The Oklahoma Indian Clinic is providing a space for children to be more physically active. 

• The Sacramento Native American Health Center is implementing community and home gardens. 

The center is specifically intended for use by young families and patients with diabetes and 

hypertension. 

To conclude, the presenters stated that participants’ common theme is that partnerships were crucial to 

the success and sustainability of the projects. Councilman Antone then opened the floor for questions. 

Councilwoman Carlyle asked if the tribes in Arizona work with the Inter-Tribal Council of Arizona Tribal 

Epidemiology Center and if presenters know if anyone from that organization has attended the grant 

writing trainings.

Presenters responded that AAIP is planning to offer two or three more trainings before funding ends in 

2018. Those interested can request to have a training in their area. 

TAC Chairman, Councilman Antone concluded the session. 

Enhanced Emergency Preparedness Panel 

Ms. Mendy Spohn, administrative director for health departments, Oklahoma State Department of 

Health, started the panel by stating that three years ago, the Oklahoma State Department of Health 

collaborated with the Chickasaw Research and Population Health program on a community-wide project 

to reduce the incidence of flu hospitalizations and deaths. The project helped identify roles and 

responsibilities, data storage, and definitions. Because the outbreak occurred on Trust Lands, it involved 

several health departments, school systems, and employee worksites. 

In addition, the Oklahoma State Department of Health is working to increase risk communication 

capabilities by creating or designating liaisons between incident command systems and hospitals, city 

and county governments, and school systems. Ms. Spohn concluded emphasizing that building 

relationships and remaining active in daily activities is the core to providing effective preparedness and 

emergency response. 

Dr. Montero commented that it was great to learn about a model where state, tribal, and local health 

departments are working together. He asked panel members to specify what makes their collaborative 

efforts successful. 

Mr. Jeff Morris, institutional environmental health officer, Chickasaw Nation, responded that the 

Oklahoma State Health Department and CNDH have established personal relationships and intentionally 

trained together and shared information to break down social barriers. 

Next, Dr. Montero asked the panel how CDC could institutionalize a similar program. 
August 8–9, 2017—Summary Report Page | 13 

Ms. Spohn suggested the following activities: 

• Establish policies 

• Create a plan that is easy to follow regardless of who holds different roles 

• Build a Memoranda of Understanding to help institutionalize programs 

• Define the urgency of issues at hand and work to address them effectively 

Dr. Montero then asked what CDC could do beyond provide funding to support efforts like this or to 

step aside.

Ms. Spohn suggested that CDC build flexibility into program guidelines or grant applications, and be less 

prescriptive with requirements (e.g., forms). She suggested that CDC focus on community readiness, 

distribution of the Strategic National Stockpile materials to the appropriate people within 72 hours, 

documentation and tracking of medication administration, and improving risk communication. 

Del Yazzie, acting director, Navajo Nation Tribal Epidemiology Center, commented that Navajo Nation, 

with three state borders (i.e., New Mexico, Arizona, Utah), has made strides in building relationships 

with those states and their counties. Navajo Nation is working to coordinate on public health 

emergencies, communicable diseases, environmental health assessments, and outbreaks. At Navajo 

Nation, responding to emergencies in a coordinated way is a challenge and they need protocols for 

samples sent to the state health departments and/or CDC. Mr. Yazzie asked if CDC had any tools (e.g., 

flow chart) to help with messaging. 

Ms. Spohn replied that mind-mapping software is a good tool and that it is helpful to think about the 

public health message. If the message gets too complicated, start scheduling meetings with partners to 

determine roles, responsibilities, and top issues that need to be addressed immediately. She has some 

logic models that she would be happy to share.

Councilman Antone responded to Dr. Montero’s question regarding what CDC can do to help by stating 

that funding to tribes and allowing for flexibility is important. He emphasized the need to increase 

funding for tribes and changing policy.

TAC Chairman, Councilman Antone concluded the session. 

Tribal Testimonies Were Accepted 

Closing Prayer/Adjournment 

Dr. Montero thanked Councilman Antone for facilitating the meeting and thanked everyone for his or 

her input, recommendations, and ideas. He stated that CDC has been continuously improving the way it 

manages TAC meetings and that it will continue to do that to make the most of TAC delegates’ time. 

Captain Clelland thanked Chickasaw Nation hosts for their gracious hospitality. 

Councilman Antone thanked the state of Oklahoma and tribes. 
August 8–9, 2017—Summary Report Page | 14 

Acronyms Table 

AI/AN American Indian/Alaska Native 

AAIP Association of American Indian Physicians 

ATSDR Agency for Toxic Substances and Disease Registry

CDC Centers for Disease Control and Prevention 

CNDH Chickasaw Nation Department of Health 

IHS Indian Health Service 

IRB Institutional Review Board 

NCBDDD National Center on Birth Defects and Developmental Disabilities 

NCCDPHP National Center for Chronic Disease Prevention and Health Promotion

NCIPC National Center for Injury Prevention and Control

NIHB National Indian Health Board 

NOFO Notice of Funding Opportunity 

OSTLTS Office for State, Tribal, Local and Territorial Support

PHAB Public Health Accreditation Board 

STAC Secretary Tribal Advisory Committee 

TAC Tribal Advisory Committee 

TEC Tribal Epidemiology Center 

TSU Tribal Support Unit